Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Monday, January 17, 2005

The American Century is Over

I am determined to keep this site on topic, but it isn’t easy. We are cursed to live in interesting times, and many subjects demand attention. Times are so interesting, in fact, that we cannot understand the prospects for the public health without considering the grand historical context.

The 20th Century was truly the American Century. It was the century when the United States, thanks to struggle, courage and sacrifice, became better. Women achieved the full legal status of persons, and while we are still far from true equality between men and women, we are indisputably much closer than we were in 1919. Workers died as numerous and nameless as flocks of starlings, in mines, factories, and farm fields, crushed, mangled and poisoned; machine gunned by police, soldiers, and mercenary armies; beaten to death by goons. But in the end they won the basic dignity and decent life we take for granted today: The descendants of slaves, spilling rivers of their own blood, at last also won legal recognition of the fullness of their humanity and citizenship.

As a people and a polity, we recognized that liberty does not only mean freedom from oppressive government. It also requires democratic government that actively defends the people’s liberty -- from private rapacity that would despoil our common heritage and crush the weak, from deprivation in sickness and old age, from bigotry and communal conflict, and from gross inequality of means and opportunity.

The United States also became a dominant and generally admired force in the world. Our leaders made many mistakes and committed many atrocities, but we are still honored for mobilizing our entire society to save the world from Hitler and Imperial Japan. The same African Americans who inspired the world by their struggle for equality gave the world the definitive musical language of the age. Our movies, our literature, our scientific discoveries and technological achievements enriched all of humanity. In spite of the frequently hypocritical, exploitive and crudely self-interested actions of our governments toward weaker countries, the U.S. still managed to acquire a store of moral authority, at least for its stated principles. And our dynamic, innovative economy created a resource base that made Americans believe in limitless possibilities.

Some of our accomplishments with the most direct and obvious relevance to public health included the National Environmental Policy Act, the Clean Air Act and Clean Water Act; Medicare and Medicaid; and the development of the Centers for Disease Control and Prevention and its U.S. Public Health Service into the world’s most capable and effective public health agency. In many respects we continue to fall short of the public health accomplishments of other wealthy countries, but that is mostly because we continue to have more inequality and a weaker social safety net than they do. Nevertheless the United States grew more than wealthy enough to solve these problems, and for a time, it appeared the will might be there to do it.

Now, tragically, disastrously, all of these accomplishments are being squandered and destroyed. Our wealth is being plundered, our progress as a society reversed, our people impoverished, our influence in the world demolished, our freedoms stolen, our future blighted. How has this come to be? What must be done to reclaim our national heritage and win back our future? I will address these questions tomorrow.